THAC0403 Same-Day ART Initiation in HIV/STI Testing Center in Bangkok, Thailand: Initial Results From Implementation Research Pich Seekaew, MPH Program Officer PREVENTION The Thai Red Cross AIDS Research Centre (USAID Linkages Program), Thailand This work was made possible by the generous support of the American people through the United States Agency for International Development (USAID) and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR). The contents are the responsibility of the LINKAGES project and do not necessarily reflect the views of USAID, PEPFAR, or the United States Government. LINKAGES, a five-year cooperative agreement (AID-OAA-A-14-00045), is led by FHI 360 in partnership with IntraHealth International, Pact, and the University of North Carolina at Chapel Hill.

Authors Pich Seekaew1, Nipat Teeratakulpisarn1, Pongsakorn Surapuchong1, Somsong Teeratakulpisarn1, Sorawit Amatavete1, Pintip Jomja1, Chotika Prabjunteuk1, Chonthicha Hanaree1, Watcha Chaison1, Prapaipan Plodgratoke1, Klayduean Singhaseni1, Danai Lingjongrat2, Surang Janyam3, Panus Na Nakorn1, Sutinee Charoenying4, Stephen Mills4, Ravipa Vannakit5, Praphan Phanuphak1, Nittaya Phanuphak1 1Thai Red Cross AIDS Research Centre, Bangkok, Thailand, 2Rainbow Sky Association of Thailand, Bangkok, Thailand, 3The Service Workers In Group Foundation, Bangkok, Thailand, 4FHI 360 and USAID LINKAGES Project, Bangkok, Thailand, 5Office of Public Health, U.S. Agency for International Development Regional Development Mission Asia, Bangkok, Thailand

Outline Background Program Design and Implementation Outcome Measures Challenges What’s Next?

Background Subpar performance on the 2nd and 3rd targets of UNAIDS’ 90-90-90 Bangkok: 57% and 79% for 2nd and 3rd 90, respectively Median CD4 at diagnosis is approximately 160 cells/mm3. Long waiting time for baseline lab results 2 to 4 weeks Multiple preparatory visits prior to ART initiation Physician factors: Refuse to start treatment among those with high CD4 count Personal judgement on client readiness Complicated process of changing assigned hospital under health benefit scheme

Objectives Describe Same-Day ART using “Initiation Hub Model” Assess feasibility of Same-Day ART Examine if Same-Day ART service improves: ART uptake after HIV diagnosis Viral load suppression

Primary Outcomes Same-Day ART (July 2017 – April 2018) Acceptability Clinical characteristic Time period of ART initiation Linkage to care Viral load suppression Comparison with historical data (February 2015 to April 2017) Clients from Thai Red Cross Anonymous Clinic

Thai Red Cross Anonymous Clinic Large HIV and STI testing center Provides research-based HIV and STI services Stand-alone VCT with 150-200 HIV tests (~8% positive) per day

Same-Day ART Eligibility Criteria Willing to start ART (non-coercive) ART Naïve Able to come back for follow-up visit(s) Results from symptomatic screening/chest X-ray/Gene Xpert MTB/RIF not indicative of tuberculosis Results from symptomatic screening/cryptococcal antigen test not indicative of cryptococcal meningitis Symptomatic screening not indicative of serious opportunistic infections that would likely require hospital admissions

Same-Day ART Algorithm ART drug regimen: FTC/TDF + EFV Baseline tests: Creatinine Urinalysis CD4 count HBsAg Anti-HCV Syphilis serology ALT Chest X-Ray Cryptococcal Ag (CD<100 cells/mm3)

ART Initiation Hub Model at the TRC Anonymous Clinic

Baseline Characteristics and Acceptability HIGH LEVELS OF ART ACCEPTABILITY ACCEPTABILITY STRATIFIED BY POPULATIONS (TRC Anonymous Clinic, Jul 2017 – April 2018, Unpublished)

Clinical Characteristic: CD4 Level (TRC Anonymous Clinic, Jul 2017 – April 2018, Unpublished)

ART Initiation Time Periods (TRC Anonymous Clinic, Jul 2017 – April 2018, Unpublished)

ART Uptake After HIV Diagnosis PLHIV initiating Same-Day ART were 3.9 times more likely to start ART when compared to standard of care arm (HR: 3.9; 95%CI: 3.7-4.2; p<0.001). (TRC Anonymous Clinic, Jul 2017 – April 2018, Unpublished)

Retention-in-Care After ART Initiation 89.64% were successfully referred to long-term ART site* Median (days) IQR: 56 (38-70) Among those who were not referred, 4 stopped ART (2 by physician due to ART-related side effect) *Assessed among those who reached 75 days after ART initiation (TRC Anonymous Clinic, Jul 2017 – April 2018, Unpublished)

Viral Load Suppression 93.9% of clients who received VL testing were virally suppressed Median (days) IQR: 162.5 (130-188) PLHIV initiating Same-Day ART were 2.2 times more likely to be virally suppressed when compared to standard of care arm (HR: 2.2; 95%CI: 1.9-2.6; p<0.001). (TRC Anonymous Clinic, Jul 2017 – April 2018, Unpublished)

Challenges Labor intensive Essential baseline laboratories may not be available in some settings (e.g. Gene Xpert MTB/RIF, same-day CD4 result, Cryotococcal antigen test, etc.) Concerns from healthcare professionals Client readiness Clinical safety Long-term data depends on referred ART sites

What’s Next? Scaling up to other provinces in Thailand Need health systems that support an increase in number of PLHIV on ART (e.g. Key Population-led Differentiated Service Delivery) More data on: Long-term health implications of Same-Day ART Qualitative assessment (quality of life, patient’s readiness, provider’s readiness, etc.) Cost-effectiveness

Acknowledgements Persons Living with HIV Thai Red Cross AIDS Research Centre Praphan Phanuphak Nittaya Phanuphak Nipat Teeratakulpisarn Pongsakorn Surapuchong Somsong Teeratakulpisarn Pintip Jomja Sorawit Amatavete Chotika Prabjuntuek Chonthicha Hanaree Watcha Chaison Prapaipan Plodgratoke Klayduean Singhaseni Ratchadaporn Meksena TRCARC staff Thai Red Cross Anonymous Clinic staff PREVENTION staff UCSF Diane Havlir Funding support Thai Red Cross AIDS Research Centre PEPFAR/USAID LINKAGES Thailand /FHI 360 Industry Thai Government Pharmaceutical Organization Janssen Atlanta CBOs Rainbow Sky Association of Thailand SWING

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